Does pneumatic dilation still have a role in the treatment of achalasia? Go with an alternative

This is half of a two-part debate — read the opposing argument. The opinions expressed here are that of the author and do not represent the position of AGA.

Achalasia is a chronic disorder and hence, treatment should be aimed at the long term. Generally, there are three different treatment options for achalasia that can provide a permanent effect: pneumatic dilation, peroral endoscopic myotomy (POEM) and Heller myotomy. Endoscopic injection with botulinum toxin at the lower esophageal sphincter (LES) always has a temporary effect; after three to six months the LES pressure is back to the pretreatment state and the symptoms will have returned. Therefore, botulinum toxin injections cannot be considered a permanent solution for this chronic disease and this treatment is thus reserved for patients that cannot tolerate a more invasive treatment or when ionizing radiation is unwanted, e.g. during pregnancy.

Of the permanent treatments, pneumatic dilation is the simplest and fastest technique. It is easy to learn and perform independently, which is probably why it is so popular amongst gastroenterologists and why it is much more often performed than POEM and Heller myotomy.

However, the efficacy of pneumatic dilation is often disappointing. It is not easy to assess the efficacy on the basis of the available scientific literature, since there is a large variety in dilation protocols for achalasia. Some centers will dilate only once with 30 mm while others always perform a 30-35-40mm dilation schedule. However, generally the one-year efficacy after one to three dilations varies between 70 and 80 percent. Longer follow-up data from multiple randomized studies suggest that after the initial treatment session, only about 50 percent of patients are still in remission after five years. Many patients thus will need to undergo multiple treatments, which are often preceded by diagnostic evaluations with upper endoscopy, manometry and barium esophagograms.

Pneumatic dilation works by stretching or tearing the muscular fibers of the LES, but it does not affect the contractions in the tubular esophagus. This is probably why in type III achalasia, where spastic contractions of the esophageal body musculature induce retrosternal pain and dysphagia, the procedure is markedly less effective than in type I and type II. The available information strongly suggests that, in this day and age, pneumodilation for type III achalasia should be discouraged explicitly. POEM and Heller myotomy are highly effective alternative options for these patients.

When pneumatic dilation is selected as treatment, usually multiple dilations are performed. Upon each recurrence, patients are retreated with another dilation. Not infrequently we see patients referred to our clinic that have been treated with more than 10 dilations in the past. Each dilation again caries the risk of complications and patients will need to fast, travel and take leave from work before each procedure. It is thus a burden for both our busy endoscopy departments and our busy patients. I always inform patients that if they decide to go for treatment with pneumatic dilations, it is very likely that they will need subsequent treatments in the next few years.

Besides the high recurrence rate, pneumatic dilation can lead to serious complications. In approximately 1 to 3 percent of dilations a perforation occurs, which can result in mediastinitis and sepsis, prolonged hospitalization, emergency surgery and death. Although it is now commonly accepted that the initial dilation should not be performed with a 35- or a 40-mm balloon, there are no other risk factors for perforation that can be taken into account, which means it can occur in each patient and with every doctor. Other complications, such as severe post-dilation chest pain, occur in 10 to 20 percent of the patients and are often a reason for an emergency care visit.

In approximately 1 to 3 percent of dilations a perforation occurs, which can result in mediastinitis and sepsis, prolonged hospitalization, emergency surgery and death.

About a quarter of the patients that underwent pneumatic dilations will develop moderate to severe reflux symptoms and/or erosive reflux esophagitis. Most of these patients will need to take proton pump inhibitors permanently in order to control their symptoms and prevent peptic strictures. For a subset of patients, this will not even be sufficient, and they will have heartburn for the rest of their lives or develop complications of longstanding reflux disease.

Perhaps even more important reasons why not to perform pneumatic dilations are the advantages of the alternatives: Heller myotomy and POEM in particular. When one studies the results of the European Achalasia Trial carefully, it is clear that a single Heller myotomy is as efficacious as a number of pneumatic dilations. The POEMA trial presented at DDW last year showed that POEM is clearly more efficacious than a series of pneumatic dilations and that it carries a lower risk of complications.

Clearly, there are also disadvantages of POEM and Heller and the results of pneumatic dilation are actually not as bad as pictured above. But a balanced view is not the desired outcome of a “Con” perspective. I leave it therefore to the reader to form an opinion after also reading the “Pro” perspective.